Healthcare Provider Details

I. General information

NPI: 1497103733
Provider Name (Legal Business Name): STEPHANIE GRAY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2016
Last Update Date: 05/03/2020
Certification Date: 05/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 S BISCAYNE BLVD
MIAMI FL
33131-2310
US

IV. Provider business mailing address

4041 INDIAN RIVER DR
COCOA FL
32927-5905
US

V. Phone/Fax

Practice location:
  • Phone: 210-248-9077
  • Fax:
Mailing address:
  • Phone: 201-310-7765
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: